TMPPM 2007 >24.5.13.3 Incontinence Procedure Codes With Limitations

Note: Any service or combination of services not identified with a # next to the procedure code, except diaper wipes, requires prior authorization if the maximum limitation is exceeded. Items identified with a # always require prior authorization. Requests for prior authorization of diaper wipes that exceed more than two boxes per month will not be considered through Home Health Services.


Procedure Code	Maximum Limitation
9-A4310	2 per month
9-A4311	2 per month
9-A4312	2 per month
9-A4313	2 per month
9-A4314	2 per month
9-A4315	2 per month
9-A4316	2 per month
9-A4320	2 per month
9-A4322	4 per month
9-A4326	31 per month
9-A4327	4 per month
9-A4328	4 per month
9-A4330	As needed
9-A4335	2 per month
9-A4338	2 per month
9-A4340	2 per month
9-A4344	2 per month
9-A4346	2 per month
9-A4349	31 per month
9-A4351	120 per month
9-A4351-SC	120 per month
9-A4352	120 per month
9-A4352-SC	120 per month
9-A4353	120 per month
9-A4353-SC	120 per month
9-A4354	2 per month
9-A4355	2 per month
9-A4356	2 per month
9-A4357	2 per month
9-A4358	2 per month
9-A4361	As needed
9-A4362	As needed
9-A4363	As needed
9-A4364	As needed
9-A4365	1 box of 50 per month
9-A4367	As needed
9-A4368	As needed
9-A4369	As needed
9-A4371	As needed
9-A4372	As needed
9-A4373	As needed
9-A4375	As needed
9-A4376	As needed
9-A4377	As needed
9-A4378	As needed
9-A4379	As needed
9-A4380	As needed
9-A4381	As needed
9-A4382	As needed
9-A4383	As needed
9-A4384	As needed
9-A4385	As needed
9-A4387	As needed
9-A4388	As needed
9-A4389	As needed
9-A4390	As needed
9-A4391	As needed
9-A4392	As needed
9-A4393	As needed
9-A4394	As needed
9-A4395	As needed
9-A4396	As needed
9-A4397	As needed
9-A4398	As needed
9-A4399	As needed
9-A4400	As needed
9-A4402	4 per month
9-A4404	As needed
9-A4405	As needed
9-A4406	As needed
9-A4407	As needed
9-A4408	As needed
9-A4409	As needed
9-A4410	As needed
9-A4411	As needed
9-A4412	As needed
9-A4413	As needed
9-A4414	As needed
9-A4415	As needed
9-A4418	As needed
9-A4420	As needed
9-A4421	As needed
9-A4422	As needed
9-A4428	As needed
9-A4455	4 per month
9-A4554	150 per month
9-A4927#	1 per month
9-A5051	As needed
9-A5052	As needed
9-A5053	As needed
9-A5054	As needed
9-A5055	As needed
9-A5061	As needed
9-A5062	As needed
9-A5063	As needed
9-A5071	As needed
9-A5072	As needed
9-A5073	As needed
9-A5081	As needed
9-A5082	As needed
9-A5093	As needed
9-A5102	2 per month
9-A5105	4 per year
9-A5112	2 per month
9-A5113	2 per month
9-A5114	2 per month
9-A5120	30 per month
9-A5121	As needed
9-A5122	As needed
9-A5126	As needed
9-A5131	1 per month
9-A5200	2 per month
9-A6250#	2 per month
9-T4521	*300 per Month
9-T4522	*300 per Month
9-T4523	*300 per Month
9-T4524	*300 per Month
9-T4525	*300 per Month
9-T4526	*300 per Month
9-T4527	*300 per Month
9-T4528	*300 per Month
9-T4529	*300 per Month
9-T4530	*300 per Month
9-T4531	*300 per Month
9-T4532	*300 per Month
9-T4533	*300 per Month
9-T4534	*300 per Month
9-T4535	*300 per Month
9-T4543	*300 per month
J-E0163#	1 per 5 years
J-E0163-TF#	1 per 5 years
J-E0163-TG#	1 per 5 years
J-E0165#	1 per 5 years
J-E0165-TF	1 per 5 years
J-E0165-TG#	1 per 5 years
J-E0167#	1 per year
J-E0168#	1 per 5 years
J-E0168-TF#	1 per 5 years
J-E0168-TG#	1 per 5 years
J-E0175#	1 per 5 years
J-E0275	2 per year
J-E0276	2 per year
J-E0325	2 per year
J-E0326	2 per year

Refer to: The Diapers/Briefs/Liners section of "Incontinence Supplies and Equipment" for an explanation of the item limitations identified with an asterisk (*).